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March 8, 2000

Fairness in Fraud and Abuse Enforcement—Reply

Author Affiliations

Phil B.FontanarosaMD, Deputy EditorIndividualAuthorStephen J.LurieMD, PhD, Fishbein FellowIndividualAuthor

JAMA. 2000;283(10):1289-1290. doi:10.1001/jama.283.10.1287

In Reply: I agree with Mr Jost that Medicare uses fraud and abuse enforcement to achieve what private insurers accomplish through active cost management. Each approach has advantages and disadvantages. Jost applauds the government's antifraud efforts, while I worry that the political seductiveness of blaming fraud for Medicare's failings distracts us from more fundamental reforms. I am also not as confident about HCFA's success. Historically, Medicare costs seesaw with those of employer-based coverage, with cross-subsidies usually running from private sector to public sector but sometimes reversing (as when Medicare was overpaying health maintenance organizations who enrolled healthier-than-average beneficiaries). One can attribute the bulk of Medicare's current comparative advantage neither to the Balanced Budget Act's1 overcorrection of previously generous reimbursement nor to aggressive fraud enforcement but to the fortuitous and lamentable fact that Medicare does not cover outpatient prescription drugs, which have overtaken hospitalization as the largest item of expense for many private insurers.

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